Quality Compliance Nurse

Overview

CLOSING DATE: 02/12/2026

Salary Range: $91,225.00 - $/Salary

APPLICANT MUST HAVE A VALID, UNRESTRICTED INSURABLE DRIVER’S LICENSE

RESUME AND REFERENCES ARE REQUIRED

ESSENTIAL DUTIES, FUNCTIONS AND RESPONSIBILITIES:

• Leads the Nursing Division through the Quality Department to ensure compliance with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.
• Assures hospital compliance with regulations and standards using regular surveys and centralized tracking.
• Assure the Nursing Division is in full compliance with all certification and licensure standards at all times.
• Coordinates with Risk Management Program to identify, prevent, and minimize risk.
• Works collaboratively with the Chief Nursing Officer through the Quality Department to evaluate quality indicators and measure the effectiveness of changes as needed for the overall improvement to the Nursing Division.
• Assists Nurse Executives in the Nursing Division in assessing, planning, and implementing quality/risk management programs in their departments.
• Participates with FDIHB hospital committees as assigned and disseminates information from the meetings to the Director of Quality, unit staff, colleagues and the Chief Nursing Officer.
• Prepares and submits reports in a timely manner.
• Supports the implementation of clinical guidelines that may include, but is not limited to, developing/obtaining appropriate education material for each nursing department’s quality process model and developing new measures/indicators that will improve the overall quality of care and safety, which we provide to our patients.
• Coordinates credentialing, nursing competencies, general orientation and ongoing staff training needs in collaboration with the Quality Division, Chief Nursing Officer, and the Clinical Education Department.
• Participates in the development and implementation of long and short-term goals as well as policies for nursing quality and safety.
• Ensures compliance with the hospital wide Quality Assessment/Performance Improvement (QAPI) Program, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, Health Care Financing Administration, and Navajo Area program requirements and identifies opportunities for patient care process improvements.
• Directs the collection, measurement and presentation of data required for monitoring quality and patient safety indicators.
• Works with Risk Manager in Root Cause Analysis (RCA) of sentinel events and reports findings to the Chief of Quality Services and the Chief Nursing Officer.
• Plans and adjusts work schedules and operations to meet established objectives, priorities, deadlines and standards of care to ensure a seamless workflow.
• Provides ongoing monitoring and evaluation of the effectiveness of hospital performance improvement and risk management programs.
• Works collaboratively with the Infection Control Program and the Safety Committee to identify and correct unsafe conditions and work practices.
• Reports unusual or questionable situations to the Director of Quality, Chief of Quality (COQ), Chief Nursing Officer (CNO), and/or Leadership.
• Provides feedback to departments and front-line staff to facilitate quality/safety implementation.
• Assists, promotes, and supports compliance with established CMS standards.
• Completes all yearly CMS required training by the indicated due dates.
• Performs other duties as assigned.

Experience:

Two (2) years of Registered Nurse experience and

Two (2) years of nursing Leadership experience and

One (1) year of Quality experience.

Education:

Bachelor of Science degree in Nursing from an accredited nursing program.

Valid and unrestricted Registered Nurse license in any U.S. State or Territory.

Valid American Heart Association (AHA) certification in Basic Life Support (BLS) and maintain certification.

Valid certifications in Infection Prevention and Control (CIC) within two (2) years from date of hire and maintain certification.

Must obtain a Specialty Certification in Quality/Infection Prevention within two (2) years of date of hire.

Please email degree, transcripts, license and certifications to Cynthia.

Morrs